Prescriber and employee utilization of a health sciences center campus outpatient pharmacy: A qualitative analysis

Abstract Purpose The college of pharmacy has operated pharmacies on campus for over 26 years. Employees and patients are users of the pharmacies; however, utilization across the campus has been limited. This paper describes a process, as well as results, that was used to gather input from employees on a large university health sciences center campus on pharmacy needs and related behaviors on campus pharmacy utilization. Methods Two focus groups of staff and 4 focus groups of prescribers were conducted over 1 month. Participants were selected through purposive sampling via email within an academic health sciences center campus over a 1-month period. The sessions were moderated by one investigator using a preconstructed discussion guide and lasted 1 hour. Two additional investigators observed sessions for nonverbal communication; all sessions were audio recorded for subsequent transcription. An open-coding process was performed on verbatim transcripts using NVivo12. The investigator team then developed, refined, and grouped themes during subsequent group discussions. Results A total of 44 participants took part in 6 focus groups. Participants included prescribers (physicians, nurses, physician assistants) and staff (nonprescribers). Two major themes identified were (1) factors related to on-campus pharmacies and (2) qualities valued in a pharmacy. There was an equal split (8% for each group) on awareness of the on-campus pharmacies. Almost 11% of participants commented on the accessibility of a pharmacy being a quality valued in a pharmacy. Conclusion Focus groups provided insights for the administration team regarding additional value-added services that would be helpful for the campus community, as well as various approaches to increase utilization of the on-campus pharmacies. Focus group methodology is an effective approach to engage employees of a large university campus to garner new ideas to enhance existing policies or services, as well as to gather thoughts on preliminary strategic plans before implementation.

Purpose. The college of pharmacy has operated pharmacies on campus for over 26 years. Employees and patients are users of the pharmacies; however, utilization across the campus has been limited. This paper describes a process, as well as results, that was used to gather input from employees on a large university health sciences center campus on pharmacy needs and related behaviors on campus pharmacy utilization.
Methods. Two focus groups of staff and 4 focus groups of prescribers were conducted over 1 month. Participants were selected through purposive sampling via email within an academic health sciences center campus over a 1-month period. The sessions were moderated by one investigator using a preconstructed discussion guide and lasted 1 hour. Two additional investigators observed sessions for nonverbal communication; all sessions were audio recorded for subsequent transcription. An open-coding process was performed on verbatim transcripts using NVivo12. The investigator team then developed, refined, and grouped themes during subsequent group discussions.
results. A total of 44 participants took part in 6 focus groups. Participants included prescribers (physicians, nurses, physician assistants) and staff (nonprescribers). Two major themes identified were (1) factors related to on-campus pharmacies and (2) qualities valued in a pharmacy. There was an equal split (8% for each group) on awareness of the on-campus pharmacies. Almost 11% of participants commented on the accessibility of a pharmacy being a quality valued in a pharmacy.
conclusion. Focus groups provided insights for the administration team regarding additional value-added services that would be helpful for the campus community, as well as various approaches to increase utilization of the on-campus pharmacies. Focus group methodology is an effective approach to engage employees of a large university campus to garner new ideas to enhance existing policies or services, as well as to gather thoughts on preliminary strategic plans before implementation.
Keywords: focus group, health sciences center campus, on-campus pharmacy, pharmacy innovation Am J Health-Syst Pharm. 2022;79:2032-2039 P harmacists are highly trusted healthcare professionals and are highly accessible for patients. 1 Patients have been documented to seek pharmacists that are patient centered and value patient-pharmacist relationships. 2,3 Patients also perceive that competence-based attributes, specifically drug safety expertise, are a primary merit of the community pharmacist. 3 Formalized quality measures, such as those approved by the Pharmacy Quality Alliance, are not well understood by many patients. 4 As a result, these measures do not commonly influence patients' choice of pharmacy. 5 Despite nearly all Americans living within 5 miles of a community pharmacy, there Prescriber and employee utilization of a health sciences center campus outpatient pharmacy: A qualitative analysis is limited literature on what attributes draw patrons to a specific pharmacy and whether accessibility carries through to place of employment. 1 A large university health sciences center (HSC) campus located centrally in a large metropolitan city houses 3 outpatient pharmacies across campus that are operated by a college of pharmacy. Other medical facilities located on the HSC campus include multiple primary care clinics, specialty clinics, an adult hospital, a children's hospital, a cancer center, a poison control center, pharmacy benefits administration, an eye institute, and a diabetes center. The college of pharmacy also owns and operates an outpatient pharmacy located on the satellite campus of the university in another large metropolitan city. These pharmacies provide services outside of traditional dispensing, including immunizations and adherence packaging. New services, such as medication delivery for transitions of care and curbside delivery, are also offered to serve the campus community. Despite these service offerings, a survey conducted by campus administration in spring 2019 to gather employee perspectives on various campus resources and entities identified that there was low awareness and utilization of campus pharmacies. Identifying healthcare provider and campus employee perspectives, as well as desired pharmacy services, will greatly aid in enhancements to the pharmacies to better meet the needs of the HSC and surrounding community. Focus groups are an effective way to elicit perceptions from healthcare providers or consumers and can be used in any area to aid in administrative decision-making. The objective of this study was 3-fold: (1) to identify awareness of campus pharmacies and services offered; (2) to determine perspectives on what is expected from pharmacy services and what can be provided; and (3) to identify facilitators and barriers, including resource-related, attitudinal, situational, and other factors, to utilization of campus pharmacies. This study was approved by the institution's review board committee.

Methods
Qualitative and quantitative research methods were used to gather information from focus groups across the HSC campus. Focus group methodology is a relatively inexpensive process that allows for guided, semistructured, and in-depth conversations that seek to answer key questions while providing insightful beliefs and understanding from participants. A preconstructed guide was developed to facilitate the focus group discussions (see Appendix for a copy of the guide). Eight focus group sessions were proposed on different days between October 1 and October 31, 2019. Six focus groups consisted of nonprescribing staff employees, and 2 focus groups consisted of prescriber employees.
Focus group guide. Grounded theory was used to develop separate guides for the focus groups targeted at prescribers vs nonprescribing staff. Grounded theory features an inductive design used to study social experiences and explain processes, as opposed to testing an existing theory. 6,7 Consistent with this approach, study investigators developed targeted yet open-ended questions to elicit data.
The investigators operationalized the study objectives into specific, openended questions to elicit information from participants regarding on-campus pharmacy services. Separate guides were used for prescriber and nonprescriber staff focus groups. The questions on the guide were not piloted but were vetted internally among the college's pharmacy and operations committee to ensure that the desired information would be captured from respondents.
Participant selection. Purposive sampling and snowball sampling within the staff/prescriber-based groups at the HSC campus were used. [8][9][10] An email describing the study and detailing information for signing up for a preidentified focus group date was disseminated to all campus employees (approximately 9,000 people) before the study start and again midway through the study. College of pharmacy employees were not eligible to participate. The focus groups were conducted at various locations within the HSC campus at either 7 am or 12 pm to accommodate the various work locations and schedules of participants. Participants emailed or called a designated study investigator to sign up for the day of their choice and eligibility (prescriber vs staff ). Participants were encouraged to share the information about the study with their colleagues.
setting. Each focus group was moderated by one study investigator using the preconstructed interview guide. 11 Each focus group comprised up to 10 healthcare prescribers or staff, and each session comprised either all prescribers or all nonprescriber staff. During the prescriber focus groups, each prescriber spoke on behalf of their patients as providers or themselves as employees utilizing the pharmacies. The primary difference between the 2 focus group guides was the inclusion of questions related to referring patients to the pharmacies and whether patients' needs were being met. The sessions lasted 1 hour, and participants

KeY PoiNts
• Utilization of focus groups can greatly contribute to understanding of attitudes and behaviors in any area of healthcare as well as large university health sciences centers.
• Factors related to on-campus pharmacies and qualities valued in a pharmacy were the major themes that emerged from the focus groups.
• Data produced from the focus groups generated ideas for expansion of services and offerings in our pharmacies that will better meet the needs of our campus community.
aM J heaLth-sYst PharM | VOLUME 79 | NUMBER 22 | NOVEMBER 15,2022 were provided with either a continental breakfast or lunch and a $25 gift card for their time. 12,13 Participants could opt out of the focus groups at any time. Data collection. At the beginning of each focus group, the moderator introduced each member of the study team, as all team members remained for the duration of the session. Each participant then introduced themselves and described their role on campus. The discussion opened with identifying each participant's awareness of the pharmacies on campus. The investigators recorded all focus group sessions with an audio-recording device. A third-party professional service transcribed all audio recordings. Four investigators reviewed each transcript and adjudicated any uncertainties to ensure accuracy. Two investigators also took notes during each focus group session to record nonverbal communication and to ensure proper interpretation of vocal inflections from the transcriptions.
Data analysis. Transcripts were imported into qualitative data software (NVivo12; QSR International, Burlington, MA). 14 results Six focus groups were completed with a total of 19 providers and 15 staff (N = 34). All participants completed the duration of their respective focus group session. Participants learned of the study either through the email that was disseminated or through their colleagues.
Two major themes were identified from participants' responses: (1) factors related to on-campus pharmacies and (2) qualities valued in a pharmacy (Table 1). Figure 1 provides an overview of the 2 themes identified with corresponding subthemes.  The percentage for each node represents the proportion of the total coded data that was related to each node.
prescribers but mostly was identified as an area for improvement (8%

ImmunizaƟons and Vaccines
Factors Related to On-

Pharmacy Services
Adherence Packaging

Meds-to-Desk
Meds-to-Bed

Product Availability
Over-the-counter (OTC) Products Product availability of nonprescription items, prescription products, and vaccines was also addressed as a distinguishing quality of a pharmacy. Pharmacy efficiency, specifically comments regarding wait times, was mentioned infrequently relative to other topics by staff and prescribers in the focus groups. Experiences with external (not on campus) pharmacies, both positive and negative, were also referenced relative to the on-campus pharmacies but by very few people.

Discussion
A recent organization-wide survey conducted by administration of the HSC identified low utilization of campus pharmacies among campus employees. Consumers of services in any area of healthcare can often give insight on potential improvements relating to utilization, efficiency, or safety of the care delivery processes. Focus group methodology can elicit such information and lead to effective and efficient improvements by the institution as these changes are based on the insightful perceptions of an individual or group within the organization who impact clinical and/or economic outcomes as well as strategic plans. Information garnered from focus groups can ultimately aid in administrative decision-making. Information generated from the focus group sessions reported in this paper affirmed the service expansion ideas the pharmacy operations team were currently developing along with providing new ideas for other expansion opportunities. One example of a previously identified service idea that garnered substantial excitement and lively conversation from the focus group participants and exceeded the expectations of the investigators was the meds-to-desk service. We identified this service opportunity due to access barriers such as lack of parking at the pharmacies and not having a drive-thru pharmacy. With the structural reality of the pharmacy locations in physician clinics, the pharmacy operations team discussed the idea of a delivery system that would take medications to employee work areas. Thus, the meds-to-desk delivery concept was started. It was a top discussion item by the focus group panels, which solidified plans to proceed with implementing the service. This service idea directly addresses multiple areas that panelists shared were barriers to utilization or valued qualities of pharmacies: hours of operation, convenience, and lack of a drive-thru. Several participants commented on the hours of operation for the pharmacies and weekend access. The hours were expanded in spring 2019, but the comments received during the focus group sessions highlighted that many were unaware of the updated hours and identified the need for increased marketing efforts for the pharmacies. Owing in part to the need of the hospital's emergency department to provide access to medications quickly and in recognition of how valued drive-thru services were to the focus group participants, coupled with a general lack of parking on the HSC campus, a curbside delivery option at 2 of the pharmacy locations on the HSC campus as well as the satellite campus was implemented. This was added immediately after the focus groups concluded and was expanded to other locations in the months afterwards due to the coronavirus disease 2019 (COVID-19) pandemic to facilitate patient access to medication while limiting the number of people in the buildings and pharmacies to ensure social distancing. To address the financial concerns of employees, the pharmacy operations team also developed a discounted formulary for the pharmacies to assist both employees and patients without insurance or with financial challenges. Some of the product offerings suggested by focus group participants are also under consideration to be added as part of the nonprescription product offerings (eg, durable medical equipment).
An adherence packaging service was also implemented in March 2020 but was underutilized by patrons of the pharmacy before conducting the focus groups. The focus group discussions raised awareness that additional marketing and dissemination of information was needed as many, again, were not familiar with the service offering or even what adherence packaging entailed. It is anticipated that this service will continue to grow along with the meds-to-desk program with greater awareness through marketing efforts.
Immunizations are a service the pharmacies have offered for several years, but discussions during the focus group panels raised awareness that this, too, needed increased marketing efforts for the service offering. An interesting finding was that many prescribers were not aware that pharmacists could administer vaccines. Some expressed thoughts about the convenience they could offer their patients to have pharmacists administer vaccinations in the pharmacies located on campus.
One of the biggest opportunities identified from the focus groups was the need for increased marketing. Hence, overall marketing efforts were increased to communicate information about the pharmacies and service offerings. Examples include additional marketing materials developed to promote the upcoming meds-to-desk program. A free college of pharmacy-branded insulated lunch tote will be provided to all participants enrolling in the meds-to-desk service for the first time. Email fliers were distributed, and the college's and university's websites were updated to include information about the medsto-desk program as well as expanded details on the different pharmacy locations and other service offerings. To help raise awareness of where the pharmacies are located, along with their business hours, informational brochures were created with maps identifying where the pharmacies are located, hours of operation, and contact information and were disseminated across campus clinics and academic centers. Informational televisions placed strategically throughout the various clinics and hospitals on campus were also updated to include information about the pharmacy locations and hours of operation. One of the pharmacies was remodeled, and, at the completion, an open-house event was held for all employees within the clinic building to promote awareness. Those who came to the open house got a tour of the pharmacy, met the pharmacist in charge, and received a brief overview of pharmacy services, a brochure of all pharmacy services offered, and a magnet detailing all pharmacy contact information and hours of operation. Finally, the curbside delivery service will continue, even as restrictions in place for COVID-19 begin to relax. Website and social media enhancements/functions are being reviewed to also help address barriers such as access and convenience. It is expected that utilization of the new services and continuation of recently implemented services will increase as a result of the intensive marketing efforts. There are plans to resurvey campus employees with the same questions to assess the impact of these efforts.
Readers should consider that our analysis and identified themes were based on the reviewer's comments. The authors did not go back to the focus group participants to verify whether our themes captured their intended thoughts. However, we feel that this limitation does not compromise our findings because the leader of the focus groups would frequently repeat and verify the comments of respondents. Additionally, we had observers record the nonverbal cues of respondents as a means to increase our confidence in accurately understanding respondents' statements and thoughts.
conclusion Despite the robust conversations generated, we experienced some challenges in gathering participants for the focus groups. Although our focus group sessions generated substantial discussion among participants and the focus group leader, including several questions from participants regarding our preliminary pharmacy programs, aM J heaLth-sYst PharM | VOLUME 79 | NUMBER 22 | NOVEMBER 15, 2022 our time was limited to 1 hour to accommodate the unique schedules of prescribers and staff working fixed shifts in clinics and departments.
Our use of focus groups to collect healthcare prescriber and campus staff perspectives will greatly aid in continued enhancement of our pharmacies' clinical services and operations to better meet the needs of the HSC campus. Focus group methodology was found to be an effective approach to solicit consumer perceptions and can be applied to any area of healthcare or university settings. These data will aid in administrative decision-making and ultimately lead to improvements in healthcare services provided by the institution.

Disclosures
The authors have declared no potential conflicts of interest.